Tuesday, Sep 25 2012
• 10 a.m. (ET)

The Pluses And Minuses Of Electronic Medical Records

As part of the 2009 stimulus package, doctors and hospitals in the U.S. were offered financial incentives to switch to electronic medical records. Three years later, more than one-third have moved to digital. While the change has improved efficiencies and patient safety, there is rising concern about the vulnerability of the system to fraud. One recent study found that hospitals received billions more in Medicare reimbursements following the switch to digital records. And patient privacy concerns remain. Guest host Tom Gjelten and a panel of experts discuss the positives and negatives of electronic health records.

Guests

Dr. Don Detmer
Professor of medical education at the University of Virginia.

Dr. Farzad Mostashari
National coordinator for health information technology at the Department of Health and Human Services.

Dr. John Dooley
Internist at Foxhall Group in Washington, D.C.

Transcript

10:06:55

MR. TOM GJELTENThanks for joining us. I'm Tom Gjelten of NPR, sitting in for Diane Rehm. She's on vacation. More than a third of the nation's hospitals now use electronic medical records. Supporters say the change has lead to greater efficiency and better patient care. But critics say it's made the system vulnerable to fraud. Joining us in the studio to discuss the concerns over electronic medical records: Dr. Don Detmer of the University of Virginia, Fred Schulte of The Center for Public Integrity and Dr. Farzad Mostashari of the Department of Health and Human Services.

10:07:29

MR. TOM GJELTENAnd joining us on the phone is Dr. David Levin, chief medical information officer at the Cleveland Clinic. This is a topic that concerns all of us, and you can join our conversation a bit later in the program with your own comments and questions about electronic medical records. Call us at 1-800-433-8850, write us an email, drshow@wamu.org, or get in touch with us via Facebook or Twitter. Good morning, everyone.

10:07:58

DR. FARZAD MOSTASHARIGood morning.

10:07:58

DR. DON DETMERMorning.

10:07:58

GJELTENDr. Mostashari, electronic medical records have been around for a while but explain what the government's interest has been in promoting wider use of electronic medical records. Your department at HHS is overseeing this effort, correct?

10:08:18

MOSTASHARIYes. We're working closely with the Center for Medicare & Medicaid Services to create some incentives, and it's worked. So over the past two years, we've really made more progress on the adoption of the records than in the 20 years before that. And we're going to see the majority of care delivered through electronic health records, I predict, by the end of this year. But, more importantly, we said it's not having an electronic health record that in the past have been used for documentation and billing.

10:08:48

MOSTASHARIIt's using it in a way that's meaningful for patients to improve the safety of patients, to improve the quality of care, to help the health care providers manage all of their patients, not just those who walk in the door most commonly. So this has been really a shift away from electronic health records for documentation and billing and towards electronic health records as really tools for prevention and tools for managing care that is going to be increasingly important.

10:09:15

GJELTENAnd what's the history of the U.S. Government, the federal government, HHS, promoting more use of electronic medical records?

10:09:24

MOSTASHARIThis has been bipartisan support for health information technology and electronic health records. My office, the Office of the National Coordinator for Health IT was created by President Bush. And this has been really something that both sides, of all sides have said, if we're going to get health care that's higher quality that produces better health at lower cost, we just need better information and better management of information.

10:09:50

GJELTENDr. David Levin, at this point, your clinic is a big advocate of using electronic medical records, if I'm correct. How widespread in your view is the adoption of electronic medical record keeping in the U.S. right now?

10:10:07

DR. DAVID LEVINSo everything I read is consistent with what was mentioned earlier, about a third, a little higher if you look at office practices, almost 40 percent. Of course, at the clinic, this is -- we were early adopters. This is something we've been working on really since around 2000, 2001 and have been very pleased with the results that we've gotten over time.

10:10:32

GJELTENAnd why have you been pleased? What is it that you have been most pleased by in the, you know, with the switch to electronic medical records?

10:10:42

LEVINWell, I think, it starts with recognizing the limits of paper-based systems. And while we've struggled for decades to drive improvements and quality and overall value by reducing costs, whether those are not appropriate, it's very difficult to do that on a paper world. If you think about the comparison to other industries that have made this migration and the kind of benefits that they've seen, we're tracing a similar course in health care.

10:11:11

LEVINSo it starts just with the simple idea that the basic clinical information is available to the care team and to the patient and their love ones as well. So simply having that information readily available, regardless of location, has been a big improvement to begin with. In our system, as patients move around from different hospitals, from the physician's offices and like, that information follows them. That's been incredibly powerful. But that's really just the prelude.

10:11:45

LEVINThe opportunity to begin to build some intelligence into these systems in the form of clinical decision support and the idea there is to help ensure that we do the right things and that we avoid doing the wrong things. So as a simple example, if a physician goes to prescribe a medication that a patient is allergic to or may have some other contraindication to, in a paper world, it's really totally reliant on that individual to be sure that they make that connection.

10:12:17

LEVINIn the electronic world, we can provide reminders about that. And in the end, it’s still important for the clinician to make that decision. But these sorts of reminders can be extremely helpful. The other thing that we are seeing is, as was mentioned, this is going far beyond the sort of basics that we did in the past. It's creating a very rich source of clinical information. And that is powering our research, our ability to learn more about how to render the best care.

10:12:54

LEVINAnd my feeling is we're really just at the beginning of that, that we're going to see a vast increase in the amount of data that's available, and then the research opportunities will grow exponentially as well.

10:13:08

GJELTENOK. Now, this is all taking place in a political context. We have great concerns about the future of Medicare, about keeping health care cost down. Dr. Don Detmer from the University of Virginia, I want to go to you now. Put this issue in this context of concerns about the future of Medicare in particular.

10:13:28

DETMERSure. Thank you. Good morning. It's nice to be here. Yes, I think there are two major policy streams that are somewhat colliding here. One is a need to reform the way physicians are paid so that we are not doing a fee-for-service, after the fact procedural, enhancing kind of way to move to actually purchase value which -- that Congress has mandated. Both sides of the aisle are in favor of it. So there's a goal to move in that direction, but the policy hadn't caught up with what has happened with the high-tech boost to funding electronic health records.

10:14:02

DETMERAnd so essentially, the implementation has really -- since that high tech came in is really moving along pretty well. But the point is obviously these things are not quite in sync and we're in a major shift, headed in the right direction but not yet where we need to be.

10:14:22

GJELTENNow, I understand that half of the doctors who treat Medicare patients now use electronic data.

10:14:28

DETMERThat's roughly correct, yes.

10:14:29

GJELTENMm hmm. Fred Schulte, I want to it bring to you now. So this all sounds like a good idea. All these arguments make a great deal of sense. What did your study of the use of electronic medical records conclude?

10:14:43

MR. FRED SCHULTEWell, we look primarily at billing and millions of individual Medicare billing records over the last decade. And what we saw when we started to look at these is that, over time, the codes that doctors were submitting for billing which paid them more money and which were more complex and took a longer amount of time to do were rising pretty dramatically whereas the ones that paid them less money were diminishing. And then we started asking around as to, well, why is this happening?

10:15:13

MR. FRED SCHULTEI mean, there doesn't seem to be a lot of evidence that patients are sicker, that patients are older, that there's that much change in what patients are coming to the doctor for. And what we heard in the industry, particularly with doctors and hospitals, is that electronic health records are responsible for this increase in coding.

10:15:30

GJELTENAnd explain how that would work.

10:15:32

SCHULTEWell, you're -- there's -- for, like, a doctor's office visit, there's five different codes you can take, you can use to bill. And in the lower level, one that takes, like, five minutes time would pay, let's say for Medicare, $20. And at the highest level, taking 40 minutes of time face to face with a doctor, would pay somewhere near $140.

10:15:54

GJELTENDr. Mostashari, you've heard this. The New York Times also had a story on this over the weekend. What is the reaction in the Health and Human Services Department to this idea? I mean, these are pretty serious charges, that the increased use of electronic medical records is actually leading to fraud.

10:16:12

MOSTASHARIWell, there's two issues here that we should separate. The first is, to what extent do the electronic health records did the increased billing reflect appropriate? You document more, you do more, you know, higher-intensity visits, and the systems are able to capture that. As Don Berwick said, fundamentally, if you create a payment system where there's a premium for increasing the number of things you do or the recording of what you do, well, that's what you're going to get.

10:16:39

MOSTASHARIAnd that's why it's so important, as has been pointed out, to move beyond that, you know, you get paid for a visit if you document X amount. And to really move toward payment systems like in the Affordable Care Act, both sides of the aisle is talking about doing these kind of paying for value. How do you control the entire cost to maintain quality? The second issue is if there's fraud, right?

10:17:02

MOSTASHARIIf there is medical documentation that didn't happen, if there's documentation of care that didn't happen, that's not just bad for patient care, which is uncertain -- certainly is, it's illegal. And this -- yesterday, the secretary of Health and Human Services and the attorney general sent out a letter quite -- stating quite empathically that we're not going to tolerate that.

10:17:26

GJELTENAnd you say there are strong protections. But if there are strong protections, how has this happened?

10:17:32

MOSTASHARIThere's always going to be people who commit fraud, and there's always going to be enforcement. And I think it's important to note that we have taken under this administration very significant steps in increasing the enforcement against fraud. There's been a huge increase in the amount of identification of fraud and civil penalties and enforcement actions. And I think it's important to note that these tools also provide the means for stronger investigation and enforcement.

10:18:05

MOSTASHARIThese tools are certified, and my office creates those certification criteria. They're certified to have an audit log that records permanently and in an unalterable way, in a way that's not remotely possible, with paper to document, who did what when.

10:18:22

GJELTENAnd you're going to continue pushing this then.

10:18:23

MOSTASHARIAbsolutely.

10:18:25

GJELTENDr. Farzad Mostashari is the national coordinator for health information technology at the U.S. Department of Health and Human Services. That department has been promoting greater use of electronic medical records. And we're looking this hour at what the impact of this shift have been. We're going to take a short break. We have lots to go over. And we'll get back to this issue when we come back.

10:20:03

GJELTENWelcome back. I'm Tom Gjelten, sitting in today for Diane. The subject today is electronic medical records, something that has -- that the federal government has been promoting in the interest of health care -- better health care and more efficient health care. But some disturbing new study -- a disturbing new study from The Center for Public Integrity and some other studies as well indicating that the greater use of electronic medical records may be leading to overbilling.

10:20:35

GJELTENFred Schulte from The Center for Public Integrity, it's your organization that has done this. And before the break, you talked about some of the coding issues, some of the coding things that you have seen where doctors actually specify certain codes for the services they have given. There's also this issue that you raised called cloning. Could you just quickly go over what is the -- what are the vulnerabilities here that electronic medical record keeping have exposed?

10:21:04

SCHULTESure. Medicare only wants to pay for medical care that is what they call medically necessary so when you come to the doctor than anything that -- that's paid for than is supposed to have been necessary to cure whatever problem you had. Electronic health records make it very easy to cut and paste and move forward reams and reams of information that could be from previous visits. And when that's moved into the current visit, it can influence the coding level or drive up the bill.

10:21:33

SCHULTEAlso, there's a lot of templates that you can click. And once you click this template, then it can spit out a very detailed assessment whether that was -- whether that assessment of your health was done or not. And the thing that gets complicated here is that you're not just talking about -- I mean, out-and-out fraud where you create an electronic record for a patient that doesn't exist, I mean, we don't know that that's a common thing. There's always been fraud of that nature.

10:22:04

SCHULTEThe critics of these electronic health records are talking about something that's considerably more subtle, where, if you could, you could have, say, a level-three visit that becomes a level four because you're prompted by the electronic health record to, it suggests, well, why don't you do this and ask this question or ask that question of the patient? And then it will raise the level up to a four. And then when you're an auditor looking at this, you wonder, well, was that medically necessary? Was that -- and why are we paying for this?

10:22:30

GJELTENBut, Fred, it seems to me it's important to distinguish here between those doctors who actually cut and paste from another patient's record and put it into a -- their current patient's record. That would seem to me to be clear case -- a clear case of fraud as opposed to those cases where maybe this happened -- this upcoding happened just as a result of clicking something too quickly.

10:22:52

SCHULTEWell, not necessarily. I mean, you want to know about what happened the last time. If you have a chronic condition -- I mean, I'm not a doctor, but I've talked to enough of them about this that, if you want to know the current state of a person's health, what happened in the past is relevant. Moving that information forward so that you have a more complete record at what you're looking at now is not necessarily a bad thing. But having that influence, how much you get paid when all you did was push a button, that's --that raises some questions.

10:23:19

GJELTENDr. Detmer, what do you make of what's happening here?

10:23:23

DETMERWell, care at the speed of light is a little different than when you're dealing with paper. We can't go back to paper. We shouldn't go back to paper. But we got to always fix what's broken. And there are three pieces to that. First, we got to fix the coding thing while we also ship to paying for value. Second, we need to educate...

10:23:39

GJELTENCan I interrupt you there? What does that -- how would a doctor charge for the value of services that he or she has provided?

10:23:46

DETMERSure. What you'd like to see happen is to pay the physician or a group of people based on how well do they taking care of a patient's chronic condition so you'd get the kind of outcomes that are possible for that patient with the multiple conditions he or she may have. So the point is that you're not doing essentially just a documentation game, you're actually in the care business and using electronic record to help you better monitor the patient, involve the patient in the care through secure Web portals, having better decision support and so forth.

10:24:16

DETMERSo the coding should be really very secondary and behind the scene. It shouldn't be actually at the center of what the doctor is having to do while he's also trying to take care of patients that are sick and need attention. So that's one of the challenges. And the codes have been ambiguous in some of these instances too. So this is not new. This has been around. As I said, it's a policy issue that hasn't candidly gotten dealt with as we moved into this other area.

10:24:38

DETMERNow, having said that, we got to fix it. There's also problems with some of software. The software is not quite where it needs to be in terms of usability to physicians. But also, software that helps us really pick up bad practice and really can check for the auditing is really catching things that it should, so we have slippage there. And then, frankly, we need a lot more education. We kind of moved into this thing without clinicians or the system really, frankly, being educated enough of them, enough people, to where this is going.

10:25:07

DETMERThere's a new certification in medicine and one plan for nursing and pharmacy and dentistry to help clinicians, at least, to have more champions that can help them lead through some of this.

10:25:16

GJELTENAnd I should point...

10:25:16

LEVINTom, David Levin here. If I could just add to that.

10:25:18

GJELTENVery quickly.

10:25:19

LEVINThis is something that clinics have been very interested in, and you hear these terms appropriate and accurate. If I could just offer a different scenario, it is true sometimes the computer will offer suggestions during an office visit. But typically, it's more like a patient has come in and they've got a sore throat, turns out they also have diabetes and hypertension and are due for some other things that are appropriate in their care. And what this does is it prompts the physician to take care of those issues at the same time.

10:25:49

LEVINDoes that result in a more complex visit? Absolutely. But it's really about providing the best possible care at that moment and, of course, having the patient, there is a golden moment. So while there may be some fraud here, again, if you look at the numbers that have been published, it's a very tiny percentage. The New York Times article cited really less than 0.3 percent. So the vast majority, I think, are tying to do the right thing here.

10:26:15

GJELTENBut it seems, Dr. Levin, that there -- it's -- clearly, there has been an increase in costs associated with health care for those patients at those clinics or hospitals where electronic medical record keeping is used.

10:26:29

LEVINSo I think we have to look at that as -- that relationship and the other factors. It's true we do have an aging population. The burden of illness is growing. We've also had an economic downturn, and historically, people defer care until their problems are greater. That tends to drive up cost. And then lastly, I think, in fact, in many cases, what the computer is doing is it's allowing us to more accurately capture what was actually happening in the past. So it makes it easier to document that work.

10:27:03

LEVINSo in effect, physicians and hospitals were doing this work in the past. It was just more cumbersome to capture that and document it in a way that meets the requirements for coding. So a phrase you often hear is leaving money on the table. So it -- while it may be true that those costs are going up, I think the real question is about value, which is -- has been referenced here. This is another thing that we're very intensively involved in at Cleveland Clinic, is we do subscribe to that notion of value, which is higher quality at lower cost.

10:27:40

LEVINAs we contemplate how to get there, what we've seen is that these electronic systems are a key enabler of that. It's just impossible to imagine that future system without this kind of technology as an underpinning.

10:27:56

GJELTENI should point out here that Dr. Mostashari from Health and Human Services had to leave. It's too bad 'cause it would've been good to him part of this discussion. But before he left, he wanted to emphasize -- he wanted us to keep in mind that part of the problem here is when patients don't know what they have been charged for, don't know what services have been put on their record. And he emphasized it's very important for patients to find out, to get as much information about the care they've been charged for as possible.

10:28:25

GJELTENBefore we go on, I want to have another doctor come in to our conversation now. John Dooley is a physician with the Foxhall Internists group. Welcome to "The Diane Rehm Show," Dr. Dooley.

10:28:36

DR. JOHN DOOLEYHi, Tom. Nice to be here.

10:28:37

GJELTENAnd tell us your experiences with -- I understand that your practice does not use electronic medical record keeping.

10:28:46

DOOLEYThat's right. Not a comprehensive one, anyway. There are certain aspects of our practice for which electronic systems make a lot of sense, so our scheduling, our billing. We have a lab tracking software. We use electronic systems to relay prescriptions to pharmacies, for example. But in terms of actually keeping the documentation, the core of the documentation for our patients, we don't. And I don't want to speak entirely for our group because it's a large group, and people have other -- my partners may have somewhat different views on this.

10:29:14

DOOLEYBut I think in internal medicine, a lot of physicians find it difficult to include all of the important information in an electronic chart when they're receiving so much that's not in an electronic format to begin with. So that's one challenge. I get reports, dozens, if not, you know, more every day from gastroenterologists and ophthalmologists lab reports from elsewhere, radiology reports that come in on paper. And how one actually integrates that into an electronic system is actually very difficult.

10:29:44

DOOLEYA lot of people think we just scan it in. Well, for one thing, it takes time and money to scan things, and, for another, they're not actually searchable or indexable records at that point. They're simply photographs of the page. In fact, they're not that helpful, and it's pretty cumbersome to use.

10:30:01

GJELTENYou know, cumbersome is the word that really jumps out to me. I remember going to doctors' offices, and, you know, they stuff your records in that slot in the back of the door. And sometimes if you're -- if you've been to the doctor a number of times in recent years, that can be a stack of records that's an inch thick or something. I mean, how easy is it -- how -- I mean, isn't the cumbersomeness of those paper records a problem for doctors who need to very quickly review a patient's history?

10:30:27

DOOLEYI don't think it's as cumbersome as a lot of people outside of medical practice might think. We all organize our charts, obviously. It's not just a stack of papers, but many doctors use tabs and other things so that the paperwork is organized. You have a section for laboratory results and a section for radiology reports, consultant notes and so on. And if you keep things in a chronological order and you keep a -- some sort of running index in terms of a problem list or a medication list, it's actually very rarely difficult for me to find something that I need.

10:30:58

DOOLEYAnd furthermore, most of what's relevant for a patient that happened in, you know, recent weeks or months or years, the number of times I need to go back and find something specific from 10 years ago is pretty infrequent.

10:31:11

GJELTENDr. Detmer.

10:31:12

DETMERYes. I think disease is getting more complicated as people age. That's one issue. It sounds like he works in a very nicely organized practice. If you look at the research that was done even at -- in '91, half the time the record wasn't available in a hospital when a clinician wanted to see a patient. And if you got it half the time, you couldn't read it 'cause it was not legible, necessarily, what you needed.

10:31:33

DETMERSo there really are some steps where they show improvements as we look at this. And one of them, I think, speaking to the last comment before the national coordinator had to leave, relating to getting a patient as piece of this education, are the secure Web portals. I think most of us who have -- as patients, whether you're a doctor or not, looking at your medical record is almost like reading Sanskrit. You can't figure it out.

10:31:55

DETMERAnd I think the secure Web portals that are part of meaningful use step three and two as this moves forward will, in fact, start giving away for patients to much more engage it and also urge and essentially talk the system into making these things more understandable to everybody.

10:32:12

LEVINDave Levin. If I may add to that, this is an area of real interest and a lot of work at Cleveland Clinic as well. We have one of the largest enrolled patient populations that use our portal every day. And the kind of connection that that brings between our care teams and patients -- and their loved ones, by the way -- you know, someone who lives in the sandwich generation the ability to, with appropriate securities, help my parents with their care, oversee the care of my children, this has been a big advance.

10:32:45

GJELTENYeah.

10:32:45

LEVINWe are on our way to releasing more and more information and providing patients more opportunity to request refills, to schedule their own appointments, to ask questions. And that kind of connectivity just can't exist in the paper world. I'm certainly sympathetic with...

10:33:04

GJELTENOK. All right. We're going to come back to you. Dr. David Levin...

10:33:06

LEVINSure.

10:33:07

GJELTEN...is chief medical information officer for the Cleveland Clinic. I'm Tom Gjelten. You're listening to "The Diane Rehm Show." And before we go back to you, Dr. Levin, I wanted to go first back to Fred Schulte from The Center for Public Integrity. One of the things in your report that you pointed out, Fred, is that a few years ago, when this big push to promote more electronic medical record keeping was beginning, a number of authorities warned there was a potential here for fraud and suggested some regulations for how this push should be implemented. Tell us what happened.

10:33:48

SCHULTEWell, there were several panels that the government commissioned to look into this question, and they came to the conclusion that it was not appropriate for these electronic medical records to be helping to dictate the code or the price of the visit, and that recommendation wasn't heeded. We were told that there was considerable concern that doctors and hospitals wouldn't want to buy these machines if they thought that somehow they could be criticized or prosecuted, even, later on for fraud as a result of using the machine as a way it was intended.

10:34:26

SCHULTESo in order to encourage the adoption -- which has been, as was mentioned before, started in the Bush administration, but really got kick-started in the Obama administration -- in order to get that going and to get doctors to give away this paper environment and move to the electronic format, they thought that they didn't really need to make fraud and abuse control a priority, and it was, in fact, not made a priority.

10:34:50

GJELTENAnd, Dr. Detmer, do you think that was a mistake now looking back?

10:34:53

DETMERI don't think there's any question. I think a number of us (unintelligible) think in -- very vocally about this at that time, that, in fact, it really should be given attention by ONC or CMS or somebody because, as I said, we kind of knew this has been around, and we didn't tidy up. And I use that term very advisedly.

10:35:12

DETMERWe didn't clean up what essentially was very -- an incoherent kind of system at that point, and we're now, clearly, paying some price despite the fact, I think, at the same time, we're clearly also getting benefits from these records. So it's a mixed situation, but, yes, I think in retrospect, we should have dealt with it.

10:35:32

GJELTENDr. Dooley, are you feeling sort of vindicated as a result of some of these studies that have pointed out some of the problems that have arisen with the use of electronic records?

10:35:43

DOOLEYNo. I'd certainly like to see them succeed in the long term. I guess my view is just that the aggressive to implement these is a bit premature in the current environment where we don't have good communication between electronic systems. I mean, if I knew that the other doctors in the community where I practice used the same system or want to communicate with whatever I used, I'd be much more inclined to use that system.

10:36:10

DOOLEYBut as long as I'm getting 100 pages a day that I need to file into charts or I have to scan in, in the case of an electronic system, I just don't see what the -- how that becomes practical. Most of the systems where the electronic record seems to work the best are big systems that encompass a lot of services under one roof. I practiced at the VA for three years, and they have a terrific system. But it's terrific because the VA is a well-integrated system.

10:36:36

DOOLEYI mean, I don't have a pharmacy under my roof. I don't have radiology facilities. I don't have specialty care. I mean, I just do general internal medicine. So it doesn't -- these systems don't actually work all that well if you're still partly on paper and partly in a system or in one system and some other doctor that you work with is in a different system.

10:36:55

GJELTENDr. Dooley, have you had patients who have pressed you to go digital, you know, who have wanted sort of the reassurance, if that's the right word, to have all their records sort of neatly organized in a digital manner?

10:37:10

DOOLEYPeople ask about it not infrequently, and I explain essentially my position that I think we do pretty well using the paper. And we do have a fairly organized office, I'm proud to say, so we don't have too much of an issue with that.

10:37:21

GJELTENYeah. OK. Dr. John Dooley is an internist with the Foxhall Group. He's a doctor whose group does not use electronic medical records. We have a number of callers who want to get in on this conversation. You can call us at 1-800-433-8850. We're going to take a quick break now, and then when we come back, we will get to those calls. Stay tuned.

10:40:03

GJELTENWelcome back. I'm Tom Gjelten of NPR, sitting in for Diane today. And we're talking about the pros and cons of using electronic medical records. This is an effort that has been promoted by the federal authorities but some questions have been raised about it and about possible fraud and higher costs associated with it.

10:40:26

GJELTENMy guests are Fred Schulte, who's a senior reporter for The Center for Public Integrity -- and that's the group that did an investigation of this -- also, Dr. Don Detmer, professor of the University of Virginia and an expert on this issue, plus two practicing doctors, David Levin, who is chief medical information officer at the Cleveland Clinic, and Dr. John Dooley, an internist at the Foxhall Group here in the Washington area. And I want to read from a couple of emails here at this point.

10:40:56

GJELTENFirst of all, someone who did not sign -- or that's actually from Michelle -- talked about getting a shocking bill after she went to her doctor for an earache and found that there was a lot more costs involved in that than she had expected. She actually says that her office does not use electronic medical records, but she did a little research on this. And she found, looking online, "There are many sites that suggest how doctors can boost their billing by asking a few more questions about general health in order to justify a higher billing code. Unethical at best, fraud in my mind."

10:41:38

GJELTENDr. Detmer, how widespread a practice is that? Do you think that doctors actually sort of ask a few more questions that may not be medically important just in order to justify a higher fee?

10:41:52

DETMERWell, first of all, I'm sorry that this woman had this experience. I think our biggest limitation, sadly, in this space is we really don't have all the data we need to know really how widespread this is.

10:42:03

DETMERAnd the problem is if we blur the difference between what are legitimate coding problems, what are also abusive practices and then out-and-out fraud, and we don't have a clean way of separating those. And, candidly, we don't give awards even to innovative people to figure out ways to create kinds of software to do a better job to do this. I, you know, I don't think we're going to find easy answers to it. Very good question, totally legitimate question, but not an easy one to answer today.

10:42:30

GJELTENOK. Let's go now to Jim who's on the line from Syracuse, N.Y. Good morning, Jim. You've been following this discussion of electronic medical records. What's your view?

10:42:40

JIMYes. Thank you very much. You know, I was a former practice manager and health care CIO, so I have a different perspective on it. And that is that before electronic health records, doctors consciously downcoded because they knew that the health insurance companies would challenge their record keeping. And they felt that if they took a lower price for what they were delivering, their chances of being negatively audited were much reduced.

10:43:09

JIMSo when electronic health records came along, it became possible for them to accurately reflect what they were doing. And naturally the price for what they were paid went up because they were doing more work than they've been able to adequately document previously.

10:43:24

GJELTENSo you're saying that it may not be an issue of overbilling now under EMR, electronic medical records, but rather underbilling previously.

10:43:34

JIMAbsolutely. I mean, I worked with 75 docs in one practice, and they did that consciously. They couldn't bill for what they actually did because they knew they'd be aggressively audited for it.

10:43:47

GJELTENLet me ask Dr. Dooley if -- what his thoughts are on that because, Dr. Dooley, your practice does not use electronic medical records. Are you concerned that you are perhaps underbilling your patients?

10:43:58

DOOLEYI mean, that's a good question. Maybe we are. I know as the email -- the comment earlier stated, there are a lot of websites out there that attempt to help doctors increase their codes by -- increase their billing by increasing their codes through various add-on questions and so on. But I think the point of it, it's a lot easier to do that with an electronic health record, or you're essentially prompted to do it.

10:44:23

DOOLEYAnd that's not a reason that electronic health record should never be used, but, I mean, that's certainly an inherent problem. It just make so much easier to do that. And sometimes it's probably inadvertent as well. I think, the people are trying to move quickly in a click of button that fills your screen with a detailed examination, unless you're conscientious and you go back and you delete what you didn't actually do or you didn't ask. You wind up with a visit note to that suggesting you did a lot more than you actually did.

10:44:55

GJELTENOK. I want to go now to Deb who's on the line from Anne Arbor, Mich. But just before you give us your question, Deb, we have just got a tweet from TulsaTeresa, who says she'll only go to physicians with EMR because of enhanced security and quality associated with it. Deb, what's your view?

10:45:18

DEBHi. I have -- on the whole, I am a mental health care provider myself, so I can't imagine now not -- them. But I do see all the -- and have experienced, working in community mental health care, there has been fraud at times. (unintelligible).

10:45:40

GJELTENOK. We're having a little bit trouble hearing you. I don't know if we can keep you on the line, Deb. But you were saying, as a mental health care provider, you have seen evidence of fraud in electronic medical records that you've come across.

10:45:54

DEBOh, yes. Hang on, and I can take you off the speaker. That's what I can do.

10:46:01

GJELTENWell, I think it's probably your cellphone. Let's go to you now, Fred Schulte, on this. You know, the danger -- and this sort or applies in any time you do investigative reporting is you can find a problem but -- you know, that's pretty attention-grabbing, but you need to sort of convey how serious that problem is. What's the scope of that problem? Actually, Dr. Levin earlier said that maybe this attention has exaggerated the extent to which there really is a problem with electronic medical records. Did you address that in your work at all?

10:46:36

SCHULTEWell, what we did is -- like I said, we looked at the billing situation and found that the changes in coding have cost taxpayers, just for Medicare, over $11 billion. So I think that's a pretty significant amount of money. The thing that caught our attention about this is that, remember, this is a program that's supposed to be saving money, and the whole intent of moving to electronic health records is to eventually reduce health care costs. So what struck us as somewhat ironic that what we're now seeing is a surge in coding and therefore a surge in costs.

10:47:11

GJELTENDr. Detmer, is it possible that over time is the system sort of adjust to this that some of these discrepancies might actually work out?

10:47:20

DETMERYes. I think there's a very good chance to that. On the other hand, I think, ultimately it's a question of what do you get for your money ultimately. It's not what you pay per se but what you get for it. And the fact is that we, I think, have had a procedure-driven kind of approach that, frankly, has not paid enough attention to how we're doing in treating populations of patients, electronic records can help you do that.

10:47:41

DETMERIt's really useful to know how you're doing on a group of people you're taking care of. We can now grab that. We can get the patient engaged. So I don't think there's any question we're in a transition. But I wouldn't be too surprised if in the near term as we try to do these transitions because this other ball is still in the air, physician payment reform and system reform, for a lot of down pressures to try to squeeze, understandably, money out of a system that's the most expensive on Earth and still not getting us the best outcomes.

10:48:08

GJELTENDr. Detmer, Don Detmer, is a medical educator in the University of Virginia. I want to go now to Sonia who's on the line from Chapel Hill, N.C. Good morning, Sonia. Thanks for calling "The Diane Rehm Show."

10:48:18

SONIAGood morning. Thank you.

10:48:21

GJELTENAnd your (word?)...

10:48:23

SONIAYes. I'm -- I have private practice in Chapel Hill, and I'm about halfway between Duke and UNC. And I find that EMR has made communication actually worse. I've been requested by one of the major medical centers send copies of the patient's records into other medical center because they couldn't get them. And that's been my experience as well in trying to get (unintelligible) hospitalization...

10:48:46

GJELTENWhy would it be harder to get electronic records than paper records?

10:48:51

SONIAI don't know. I'm not the person behind the IT in either system, but they tend to send information here. That's how you can access our system, and I can't. It's not an available system. What I've done in my practice, in order to have a set of communication, is I've gone back to a combination of electronic medical records and paper chart. When I'm...

10:49:17

GJELTENYou've gone back to that?

10:49:19

SONIAYes. When I'm with the patient, I write. I don't -- I look at my patient. I don't look at the computer screen.

10:49:26

GJELTENDr. Levin, we've got you on this program as someone who uses electronic medical records, believes in them and advocates for them. So I'm going to give you a chance to respond to Sonia as well as the couple of these other callers that have raised concerns about EMR.

10:49:41

LEVINSo I think the concerns are great questions, and I think we have to begin by recognizing that we're implementing very complicated systems in a very complex environment. And so, you know, there are going to be some bumps in the road. Having said that, there are a number of things that different organizations are doing around the country to address this. So I'd like to tick off a couple of those.

10:50:06

LEVINSo the first is this move from, if you will, volume-based care to value-based care. And, you know, we've done some things very specifically at Cleveland Clinic. So, for example -- excuse me -- our physicians are salaried, so they're not paid per test or per procedure. And we're very focused when we review their work in terms of the quality and those results. The second thing is we've actually used the system to start to drive down some cost.

10:50:36

LEVINAnd a good example of that that's very well-documented is we can now present a reminder to a physician when they go to order a test that's been ordered recently to say, did you know this has already been ordered? Here's the result. Do you still want to repeat that? And we've also began to take certain highly specialized test and have the ordering of those tests be guided by specialists who have deep knowledge. Again, we've got good documentation to show where that has reduced cost. I think that's a good example of appropriateness.

10:51:15

LEVINIn terms of the connectivity that's been discussed, I certainly have sympathy for the physicians that are struggling with getting that information. In our environment, there are a couple of things that we've done. One is we've attempted to offer -- to host these systems for independent physicians that want this -- by obtaining in their practice, but may not be able to do it on their own. We've been very successful with that. We also offer, via the Internet, access to records on a limited basis.

10:51:47

LEVINAnd then, lastly, we've worked with the other health care systems in the region to do electronic exchange. And so we literally have hundreds of those exchanges occur every month when a patient goes outside of the Cleveland Clinic system. The last thing I'd like to say is that, as much I'm a proponent for the technology, really, our mantra is high tech and high touch. And part of, I think, what's been missing, as we've implemented these systems, is to ensure that we do that in a way that minimizes the interference between the patient and the physician.

10:52:29

LEVINAnd there are some very wonderful techniques that are out there. I've witnessed it myself where it actually can enhance the interaction between the patient and the physician.

10:52:39

GJELTENOK. Well, you're making some good arguments, but there's another issue that in our few remaining minutes we haven't even address yet, and I want to get to it. Arlene raises this issue, "What about the issue of security and privacy of a person's medical records? I'm an Army veteran. Twice, I've received letters stating that my medical records might have been compromised. The first time by the VA, a worker lost a computer with electronic medical records."

10:53:05

GJELTEN"And the second, through records stolen -- electronic records stolen from a worker's car in Texas." Dr. Detmer, what about this issue? Now, any time that you move to something electronic, potentially, a lot more people have access to those records. What about these concerns about privacy?

10:53:25

DETMERThe privacy area and the security area and confidentiality area is probably one of the most contentious and difficult issues to try to actually make progress on. Most parts of the world allow people to have a unique personal health identifier as a matter of national policy so that you can absolutely sure this Mary Smith is not this other Mary Smith, so that those records don't switch that way. So we have to deal with security in a very kind of curious kind of environment where we can do what we can do.

10:53:54

DETMERWe also have to try to do it in a context of all these changes. The other problem is there are vendors, and there are vendors. It's not as though all the vendors, in fact, actually work on the security issues as much as they can. And as you've heard, doctors really want to share information for our patients, so you have this inherent tension between needing the data for research, needing that for that patient care and not having necessarily have so many barriers in there that you can't actually do that, too. That can raise cost. So the cost element is also an issue there, too.

10:54:24

GJELTENDr. Don Detmer from the University of Virginia. I'm Tom Gjelten. You're listening to "The Diane Rehm Show." And Scott is on the line now from Philadelphia, Pa. Good morning, Scott.

10:54:35

SCOTTGood morning and thanks for taking my question. I'm surprised nobody mentioned the Institute of Medicine or FDA reports about health IT causing harm and not even knowing the magnitude. And copy and paste and cloning and other practices they are described can affect the accuracy of the medical record. Myself, knowing of people who've been harmed by electronic medical record mistakes, I ask the panel, how does this cloning and copying and so forth affect patient safety?

10:55:02

GJELTENScott, did you just say that, as a patient, you've been harmed by this?

10:55:06

SCOTTI know people, including a relative, who were harmed and, in fact, died as a result of electronic health record caused...

10:55:12

GJELTENHow does that happen?

10:55:14

SCOTTExcuse me?

10:55:14

GJELTENAnd how does that happen?

10:55:16

SCOTTA critical medication was simply vanished from the electronic record and resulted in catastrophe.

10:55:22

GJELTENDr. Levin, do you want to respond to that?

10:55:24

LEVINWell, first, I'm very sorry to hear about the -- what happened with your relative. I guess I would argue a couple of things. The first is those kinds of errors have occurred in the paper world as well, very well-documented. I think the IOM report -- and I'm intimately familiar with it -- raises important questions. But if it's read carefully, I think it's quite clear these are questions that have yet to be answered, and the evidence that's available is mixed.

10:55:53

LEVINAnd so what we've seen in some areas, these systems have clearly improved safety and quality without question. I would argue it's must -- again, much less likely that patients are going to get the wrong medication or wrong dose of medication that they're allergic to, that sort of thing. At the same time, there are questions that remain, and this is part of the journey that we're on.

10:56:14

GJELTENExactly. Dr. Detmer, before we go, you were on that safety panel that the caller just referred to.

10:56:19

DETMERCorrect. Correct. Actually, I had a note to mention that at some point, so that was a great curveball. Anyway -- or not a curveball, a direct pitch, a slow ball. Anyway, the study showed that we have a lot of issues here that need to be dealt with. Sharing data is important. And what we really need is to adopt some of the policies that the airline safety programs have done. So you can have confidential reporting so that you really do move two airs. The airs -- quality and safety are not doing exactly the same thing. We've got to have systems that look at safety and systems that look at quality.

10:56:50

GJELTENDr. Don Detmer from the University of Virginia. We've also been joined this hour by Fred Schulte, a senior reporter for The Center for Public Integrity, Dr. David Levin from the Cleveland Clinic, Dr. John Dooley, an internist at the Foxhall Group. I'm Tom Gjelten. You're listening to "The Diane Rehm Show."

10:57:08

ANNOUNCER"The Diane Rehm Show" is produced by Sandra Pinkard, Nancy Robertson, Denise Couture, Susan Nabors, Rebecca Kaufman, Lisa Dunn and Megan Merritt. The engineer is Tobey Schreiner. Natalie Yuravlivker answers the phones. Visit drshow.org for audio archives, transcripts, podcasts and CD sales. Call 202-885-1200 for more information. Our email address is drshow@wamu.org, and we're on Facebook and Twitter. This program is a production of WAMU 88.5 from American University in Washington, D.C. This is NPR.

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